Thank you for visiting the Health Insurance Premium Payment (HIPP) program online forms page.  To start your HIPP application, please complete the HIPP Application Form and ALL of the forms listed below.  However, the Appointment of Representative form is optional and is not required for determination of eligibility.   

English Version

• HIPP Application Form
• HIPP Application Form – Large Font
• HIPP Disclosure Statement
• Release of Information
• Medical Statement of Diagnosis
• Appointment of Representative
• Payee Data Record
• Notice to Terminating Employees

Versión en Español

• Solicitud para el Programa HIPP
• Declaración de Revelación de HIPP
• Entrega de Información
• Declaración de Informe Médico de Diagnóstico
• Nombramiento de Representante
• Beneficiario Registro de Datos (Sólo en Inglés)
• Notificación para Empleados Despedidos

Other Languages – HIPP Application Form DHCS 6172

Armenian Version – HIPP Application Form
Cambodian Version – HIPP Application Form
Chinese Version – HIPP Application Form
Farsi Version – HIPP Application Form
Hmong Version – HIPP Application Form
Japanese Version – HIPP Application Form
Korean Version – HIPP Application Form
Laos Version – HIPP Application Form
Mien Version – HIPP Application Form
Punjabi Version – HIPP Application Form
Russian Version – HIPP Application Form
Tagalog Version – HIPP Application Form
Taiwanese Version – HIPP Application Form
Ukranian Version – HIPP Application Form
Vietnamese Version – HIPP Application Form